Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+)
Summary of research *
Location: Cameroon.
What we know: A wide range of nutritional products are currently used to treat MAM; there is no definitive consensus on the most effective products to use.
What this article adds: A controlled randomised trial compared an improved CSB (CSB+) treatment with a ready-to-use supplementary food (RUSF) treatment to treat MAM. Eighty-one MAM children aged 25-59 months were enrolled and received a daily ration (50% energy) for 56 days. Fortnightly follow-up involved nutrition and general health counselling, clinical assessment and anthropometry. Recovery was good (85% in RUSF group, 73% in CSB+ group) and was not significantly different between groups. Higher weight gain in the RUSF arm (similar total energy was provided to both groups) may be due to the different nutrient contents of the products, cooking requirements and lower energy density of CSB. Fifteen per cent of RUSF group and 20% of SAM group did not recover after 56 days; 3% and 5% respectively deteriorated to SAM. Nutrition education may have improved outcomes in this study.
Moderate and severe wasting are acute forms of undernutrition; children suffering from them face a markedly increased risk of death. It is estimated that moderate acute malnutrition (MAM) and severe acute malnutrition (SAM) affect 52 million children under five years of age worldwide. Supplementary feeding programmes (SFPs) are designed to treat MAM and prevent progression from MAM to SAM, and thus have the potential to reduce child mortality and morbidity. A wide range of nutritional products are currently used to treat MAM. These include fortified blended flours, especially corn-soya blend (CSB) prepared as porridge; BP5 biscuits; and lipid-based nutrient supplements, in particular therapeutic and ready-to-use supplements (RUTF and RUSF). Product formulation and quantities used have varied in published effectiveness studies; therefore there is no definitive consensus on the most effective products to use in MAM treatment.
The purpose of this study was to compare an improved CSB (CSB+) with an RUSF programme in the treatment of MAM to test the hypothesis that supplementary foods given at complementary dose (about 50% of the child’s energy requirement) result in high recovery rates (assuming the remaining energy requirements can be met through the usual household diet). The study was a comparative effectiveness trial that assessed the treatment of MAM in children for a period of 56 days, using a controlled randomised design with parallel assignment for CSB+ or RUSF.
Eight hundred and thirty-three children aged 6-59 months living in the health districts of Mvog-Beti (urban area) or Evodoula (rural area) in the Centre region of Cameroon were screened for eligibility. Children were excluded if they did not have appetite, had a chronic debilitating illness, or had a history of peanut allergy. Eighty-one children aged 25-59 months with MAM (WHZ <-2 and ≥ -3 without oedema) were enrolled in the study from February to July 2012. Allocation to either CSB+ or RUSF groups was performed by caregivers drawing from an opaque bag containing coded numbers corresponding to one of the two supplementary foods. The code was accessible only to the food distributor. Investigators and nutrition educators were blinded to the child’s assigned food group.
On enrolment, children were examined by a paediatrician to assess their health status and de-wormed (500mg mebendazole). Caregivers were interviewed regarding the child’s socio-demographic characteristics and to assess household food-consumption score. Nutrition and general health counselling and information about the illness of their children and the benefit of supplementary feeding were provided to all caregivers. Every child received a daily ration of 167 kJ (40 kcal)/kg body weight for 56 days, provided as two-week rations every fortnight. Each caregiver also received nutrition and general health counselling at enrolment and at every follow-up visit, and was instructed to continue to feed children their usual diet along with the supplementary food as ‘medicine’. At each follow-up visit, caregivers reported on the child’s clinical symptoms and tolerance of the study food; anthropometric measurements and nutrition education were repeated. Additional supplementary food was continued for those who remained wasted. Standard methods for anthropometric measurements were used; anthropometric indices (weight-for-age Z score (WHZ), weight-for-age Z score (WAZ) and height-for-age Z score (HAZ)) were based on WHO 2006 Child Growth Standards.
The study found no significant differences between the malnutrition profile of CSB+ and RUSF groups: all the children enrolled in the study were moderately wasted, moderately underweight and moderately stunted. No adverse reactions to any of the foods were reported. After 56 days of treatment, 85% of children recovered from MAM in the RUSF group (95% CI 73%, 97%) and 73% in the CSB+ group (95% CI 59%, 87%). The mean duration of treatment required to achieve recovery was 44 days in the RUSF group and 51 days in the CSB+ group. There was no significant difference (P=0.276) in the recovery rate between the two groups (Fisher’s exact text). A non-response rate of 20% among children in the CSB+ group and 15% in the RUSF group was observed; thus these children remained moderately malnourished following 56 days of treatment. Of children in the RUSF and CSB+ groups, 3% and 5% respectively deteriorated to SAM. Children who received RUSF showed higher rates of weight gain compared with those receiving CSB+ (P<0.05).
The observed recovery rates suggest that both products were relatively successful in treatment of MAM in children, comparable to or relatively higher than those found in previous studies, despite the lower quantity of supplement provided to children. The authors suggest that this could be a reflection of the investment in education of caregivers on how best to use foods available in the house, since educational interventions have been shown to improve child-feeding practices. This suggests that, in the context of moderate food insecurity, nutrition education could improve the outcomes of supplementary feeding and reduce the quantity of supplement generally provided.
The authors suggest that the higher weight gain in the RUSF arm (despite similar total energy provided to both groups) may be due to the different nutrient contents of the products, the fact that RUSF does not require cooking, and the lower energy density of CSB+ (a child must eat eight times the mass of supplement compared to RUSF). This may have affected the global dietary intake of the children and might account for the lower weight gain and recovery rate in the CSB+ group. In Cameroon, as in most African countries, national protocols for the management of MAM recommend the use of large doses of fortified blended flours, which are usually imported. Based on the average time required for treatment in both groups and the cost of both products, the overall cost to treat a child with CSB+ (3·48 euros) was relatively lower than the cost with RUSF (3·52 euros). This calculation does not include transport, storage or staffing costs. If considering the operational limits of CSB+ requiring preparation, RUSF could be a more cost-effective choice.
The authors conclude that both CSB+ and RUSF were relatively successful for the treatment of MAM in children. Despite the relatively low ration size provided, the recovery rates observed for both groups were comparable to or higher than those reported in previous studies, a probable effect of nutrition education.
*Medoua GN, Ntsama PM, Ndzana ACA, Essa’a VJ, Tsafack JJT and Dimodi HT. (2016) Recovery rate of children with moderate acute malnutrition treated with ready-to-use supplementary food (RUSF) or improved corn-soya blend (CSB+): a randomized controlled trial, Public Health Nutrition, 19(2), pp. 363–370. doi: 10.1017/S1368980015001238.